Description
Apply information from the Aquifer Case Study to answer the following discussion questions:Discuss the Mr. Barley’s history that would be pertinent to his respiratory problem. Include chief complaint, HPI, Social, Family and Past medical history that would be important to know.Describe the physical exam and diagnostic tools to be used for Mr. Barley. Are there any additional you would have liked to be included that were not? What plan of care will Mr. Barley be given at this visit, include drug therapy and treatments; what is the patient education and follow-up?
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Family Medicine 28: 58-year-old male with shortness of breath
User: ARIADNA ZARZUELA
Email: ariadna.zarzuela@stu.southuniversity.edu
Date: September 25, 2023 6:28 PM
Learning Objectives
The student should be able to:
Discuss key features of the history and physical exam that support the diagnosis of chronic obstructive pulmonary disease (COPD).
Interpret pulmonary function test (PFT) results.
Use a validated symptom score to grade the severity of a patient’s chronic obstructive pulmonary disease (COPD).
Summarize the key features of a patient presenting with dyspnea, capturing the information essential for differentiating between the common and
“don’t miss” etiologies.
Summarize the key features of a patient presenting with paroxysmal nocturnal dyspnea, capturing the information essential for differentiating
between the common and “don’t miss” etiologies.
Recognize radiographic findings of COPD, CHF, and pneumothorax.
Discuss smoking cessation.
Apply current guidelines to make appropriate clinical decisions regarding the need for immunizations.
Use motivational interviewing to encourage appropriate lifestyle changes identified to support wellness
Find and apply diagnostic criteria and surveillance strategies for COPD.
Describe an evidence-based management plan that includes pharmacologic and non-pharmacologic treatment of COPD.
Describe an evidence-based management plan that includes surveillance and avoids complications of COPD.
Educate a patient about an aspect of COPD respectfully, using language that the patient understands.
Discuss the difference between asthma and COPD, including pathophysiology, clinical findings, and treatments.
Differentiate among common etiologies of cough.
Conduct a focused physical exam appropriate for differentiating between common etiologies of a patient presenting with cough and dyspnea.
Knowledge
Dyspnea Definition
Dyspnea is defined as an uncomfortable awareness of breathing.
Any problem in the mechanical system of breathing can trigger dyspnea, including (but not limited to):
Blockage in the nose
Fluid in the alveoli
Irritation of the diaphragm
Causes of Dyspnea
It often helps to organize your list of differential diagnoses by system, so that you make sure that it is complete. Also, an organized list can make it
easier to rule in or out the diagnostic possibilities.
One way to organize the causes of dyspnea in adults is by categories: cardiac, hematologic, pulmonary, or psychogenic:
Cardiac:
Congestive heart failure (CHF), coronary artery disease (CAD), dysrhythmia, pericarditis, acute myocardial infarction
Hematologic:
Anemia
Pulmonary:
Obstructive lung disease: Chronic Obstructive Pulmonary Disease (COPD), asthma, bronchitis
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Diseases of lung parenchyma & pleura: pneumonia, pleural effusion, cancer involving the lungs, pneumothorax, pulmonary edema, restrictive
lung disease, interstitial lung disease
Pulmonary vascular disease: pulmonary embolism, pulmonary hypertension
Obstruction of the airway: gastroesophageal reflux disease with aspiration, foreign body aspiration
Environmental irritants and allergens: dust or chemical
Psychogenic:
Panic disorder, hyperventilation
Other:
Deconditioning
Neuromuscular conditions (Myasthenia gravis, Guillain-Barre Syndrome, Amyotrophic Lateral Sclerosis)
Metabolic (carbon monoxide poisoning, anion, or non-anion gap acidosis)
Orthopnea Definition, Etiology, Symptoms
Definition
Orthopenea is dyspnea which occurs when lying flat.
Etiology
It is associated with congestive heart failure through an accumulation of excess fluid in the lungs (as a result of left-sided heart failure). In a prone
position, blood volume from the feet and legs redistributes to the lungs.
Symptoms
Patients with orthopnea typically have to sleep propped up in bed or sitting in a chair. It is commonly measured according to the number of pillows
needed to prop the patient up to enable breathing (Example: “three pillow orthopnea”).
Paroxysmal nocturnal dyspnea (PND) – Definition, Etiology, Symptoms
Definition
Sudden, severe shortness of breath at night that awakens a person from sleep, often with coughing and wheezing.
Etiology
It is most closely associated with congestive heart failure.
Symptoms
PND commonly occurs several hours after a person with heart failure has fallen asleep. PND is often relieved by sitting upright, but not as quickly as
simple orthopnea. Also unlike orthopnea, it does not develop immediately upon lying down.
Acute Versus Chronic Bronchitis
Clinical distinction between acute bronchitis & chronic bronchitis: duration of illness.
Acute Bronchitis
Chronic Bronchitis
Cough with excess sputum with a course lasting 1
to 3 weeks
Cough with excess sputum production for equal or greater than 3 months per year in each of 2
consecutive years
Classic Findings on Physical Exam that are Suggestive of COPD
COPD
Increased anteroposterior (AP) diameter of the chest
Decreased diaphragmatic excursion
Wheezing (often end-expiratory)
Prolonged expiratory phase
Physical Exam Findings Suggestive of COPD
A combination of specific findings in a patient’s history and physical may be suggestive of COPD.
Increased AP diameter and end-expiratory wheezing are generally considered to be classic signs of COPD.
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Chronic Obstructive Pulmonary Disease (COPD) – Definition, Epidemiology, Diagnosis
Definition
COPD includes chronic bronchitis and emphysema and is characterized by airflow limitation that is progressive and not fully reversible with
bronchodilators.
Chronic bronchitis: chronic inflammation in the airways leading to the destruction of the cilia and narrowing of the air passages in the lungs.
Emphysema: chronic destruction of the lung architecture, particularly the alveoli, leading to reduced air exchange.
Epidemiology
COPD is currently reported by the Global Initiative for Chronic Obstructive Lung Disease to be one of the top three causes of mortality worldwide. In
2020, 5% of the adult population has a diagnosis of COPD, emphysema, or chronic bronchitis.
Diagnosis
A clinical diagnosis of COPD should be considered in any middle-aged or older adult who has:
Dyspnea
Chronic cough or sputum production
A history of tobacco use
The diagnosis should be confirmed by spirometry.
COPD Versus Asthma
Since a major clinical distinction between these two diagnoses is that COPD is not reversible via bronchodilator therapy, and asthma is ,
spirometry data is collected twice: pre- and post-bronchodilator therapy.
Other major differences between COPD and asthma are outlined below:
COPD
Asthma
Onset in mid-life
Onset typically early in life
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Symptoms slowly progress
Symptoms vary day to day
Symptoms during exertion
Symptoms more common at night or early morning
Long history of smoking
Not dependent on smoking
Not related to rhinitis, allergy, or eczema Often related to rhinitis, allergy, or eczema
Largely irreversible
Air-flow limitation is largely reversible
Pathophysiology
Differences between the mechanisms underlying COPD and asthma include:
Cigarette smoke is more of a causal agent in COPD,
Mast cells, T helper cells, and eosinophils play more of a role in what appears to be an allergic bronchoconstrictive response in asthma, and
Macrophages, T killer cells, and neutrophils play a role in an inflammatory and destructive process in COPD.
A post-bronchodilator FEV1/FVC ratio < 70% confirms the presence of airflow limitation that is not fully reversible (hence a diagnosis of COPD).
Significant reversibility is defined as an increase in FEV1 ≥ 12% after bronchodilator.
Distinguishing COPD from Asthma
Airflow obstruction in asthma is reversible, but in COPD it is not .
The major distinction between asthma and COPD is the reversible nature of asthma's obstruction to airflow.
By definition, FEV1/FVC is decreased in COPD but can be decreased or normal in asthma if the FEV1 and FVC are both decreased proportionally.
FVC is normal to decreased in COPD but always decreased in asthma.
Macrophages and T killer cells play a role in COPD.
Note that, though this distinction of reversibility versus non-reversibility of obstruction is a general rule, this characteristic is not completely reliable.
You need to consider all aspects of the presentation, including:
Age
Smoking history
Relationship to environmental allergies
Time course of symptoms
Benefits of Quitting Smoking
Figure from study
Lung function decreased at twice the rate in patients who continued smoking versus those who quit.
Quitting smoking provided benefits whenever the person quit.
Continuing smoking or relapsing worsened lung function.
This kind of evidence can help with counseling patients and motivating them to consider behavior change.
Smoking Cessation Methods
Counseling delivered by physicians and other health professionals significantly increases quit rates over self-initiated strategies. Even a brief (3minute) period of counseling results in smoking cessation rates of 5-10%. The addition of discussing "lung age" from the spirometry testing to
counseling has been shown to increase tobacco cessation rates.
Numerous effective pharmacotherapies for smoking cessation are available, and pharmacotherapy is recommended when counseling is not
sufficient to help patients quit smoking. The U.S. Public Health Service states that a combination of counseling and medication (rather than either
alone) and effective medication should be offered (PHS Strength of Evidence A). The Quick Reference Guide for Clinicians from the U.S.
Department of Health and Human Resources recommends that except in the presence of contraindications, pharmacotherapies be used with all
patients who are attempting to quit smoking:
Seven first-line pharmacotherapies were identified that reliably increase long-term smoking abstinence rates with PHS Strength of
Evidence (SOE) Recommendation:
Bupropion SR (PHS SOE A)
Nicotine gum (PHS SOE B)
Nicotine lozenge (PHS SOE B)
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Nicotine inhaler (PHS SOE A)
Nicotine nasal spray (PHS SOE A)
Nicotine patch (PHS SOE A)
Varenicline (PHS SOE A)
Two second-line pharmacotherapies were identified as efficacious and may be considered by clinicians if first-line pharmacotherapies are
not effective:
Clonidine (PHS SOE A)
Nortriptyline (PHS SOE A)
A combination of differing counseling formats (proactive phone call, group counseling, individual counseling) increases quit rates. A combination of
medical therapies (Nicotine patch + Bupropion SR; nicotine patch + another nicotine replacement product) may also be considered (PHS SOE A).
According to GOLD 2022, due to controversy on effectives for smoking cessation and injuries caused by adulterants, E-cigarettes and vaping for
nicotine replacement therapy can not be recommended.
Physicians and healthcare organizations can support broader tobacco control efforts to raise tobacco taxes, adopt smoke-free laws, conduct mass
media campaigns, and restrict tobacco marketing to enhance clinicians' actions working with individual patients.
How to Advise Smoking Cessation
There isn't one best way to introduce the discussion about smoking cessation. The 5 As of counseling, commonly used, are based upon expert
opinion. In general, connecting smoking to the patient's reason for being at a healthcare visit, and delivering a clear and direct message about the
need to quit smoking, are believed to be most important.
The five As are as follows:
Ask: Always ask about tobacco use at every visit
Advise: Give a clear, personal recommendation that your patient should quit smoking
Assess: Ask about the patient’s readiness/willingness to quit and about prior quit attempts
Assist: For patients willing to quit, provide evidence-based counseling, resources, and if appropriate, medications, to help with their success.
Arrange: Schedule follow-up for the patient in person or by telephone/telehealth.
A Cochrane Database review found that when physicians help patients obtain free smoking cessation medications through insurance or smoker
support programs like the North American Quitline Consortium that smoking cessation rates improve.
Medications to support tobacco cessation should be encouraged for anyone who currently smokes 10 cigarettes (half a pack) per day. For further
information on this topic including medications to treat tobacco use disorder, see references from the AAFP for a good overview.
Comprehensive Assessment of COPD Severity
The GOLD organization recommends assessing a patient's severity of symptoms in addition to their degree of obstruction (based on the FEV1).
Several objective measures of COPD symptomatology have been developed, including the COPD Assessment Test (CAT) and the Modified British
Medical Research Council (mMRC) Questionnaire. Physicians should categorize patients into one of four severity groups, A through D, depending
on the combination of their testing and symptom scores. The following table explains this in more detail:
GOLD Symptom Groups Based on Symptom Scores and Number of Exacerbations:
CAT score < 10 or mMRC 0-1 CAT score ≥ 10, or mMRC ≥ 2
0 to 1 prior exacerbations Group A
Group B
≥ 2 prior exacerbations
Group D
Group C
Initial Therapy for Moderate & Severe COPD
Initial Therapy for GOLD group B
In addition to a short-acting beta-agonist (SABA) for symptoms, patients in group B should be given a long-acting beta agonist (LABA) or long-acting
muscarinic antagonist (LAMA).
Initial Therapy for GOLD group C
Patients in group C should begin initial therapy with a LAMA inhaler (evidence suggests that in this group, LAMAs are slightly more effective than
LABAs for preventing exacerbations).
Initial Therapy for GOLD group D
Patients in group D should also begin initial therapy with a LAMA. For patients with more severe symptoms, a combination LABA/LAMA can be
started instead. For patients in group D with concurrent asthma/COPD, a combination LABA/ICS may be the best first choice, especially in patients
with elevated blood eosinophils >300. The addition of an ICS can reduce exacerbations, especially in those with an allergic component (eosinophils)
to symptoms, but can also increase the risk of pneumonia.
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Follow Up Therapy
Follow up should focus on reviewing symptoms (especially dyspnea and exacerbations, which are addressed in different ways), assessing inhaler
technique and adherence, and adjusting medications (either adding or subtracting, as needed).
For patients with dyspnea despite a long-acting bronchodilator, a second bronchodilator can be added. For patients with exacerbations
despite a long-acting bronchodilator, a second bronchodilator or an ICS can be added—an ICS would be most appropriate for patients with a
history of asthma or elevated eosinophils, as described above.
For patients with dyspnea or exacerbations despite a LABA/ICS combination, a LAMA can be added. A switch to a LABA/LAMA combination
can also be considered.
For patients with exacerbations despite a LABA/LAMA combination, there are two options:
The addition of an ICS, particularly for those with asthma or high eosinophil counts.
Roflumilast (a Phosphodiesterase-4 inhibitor) or azithromycin (a macrolide antibiotic) can be added for those without asthma or high
eosinophil counts.
The cost of many of these inhalers can be a barrier to use. Methylxanthines, such as theophylline, are not recommended unless other
medications are not available or not affordable.
Oxygen therapy is indicated if room air oxygen saturation at rest is < 88%.
Pulmonary rehabilitation and/or a maintenance exercise program may help with symptoms: physical activity is a strong predictor of mortality,
so exercise should be encouraged for all patients.
CDC Adult Immunization Schedule
The CDC's complete schedule of immunizations for adults .
Vaccine Adverse Events
Rare, serious side effects associated with vaccines should be reported to the United States Department of Health and Human Services using the
Vaccine Adverse Event Reporting System (VAERS) at https://vaers.hhs.gov/. VAERS is an early warning system designed to detect problems
possibly related to vaccines; it relies on reports from healthcare providers, patients, and vaccine manufacturers to allow the Centers for Disease
Control (CDC) and the Food and Drug Administration (FDA) to ensure vaccine safety. Healthcare providers are encouraged to report clinically
significant adverse events, even if it is uncertain whether the event is related to a vaccine.
Management
GOLD Spirometric Criteria for COPD Severity
GOLD
Spirometry
Severity
Grade
Results
Clinical Presentation
FEV1/FVC
< 0.7
At this stage, the patient is probably unaware that lung function is starting to decline. Keep in mind that there is
1
Mild
some evidence that using this fixed ratio may contribute to the overdiagnosis of obstruction in older (> 60 year
FEV1 ≥
old) individuals and, to a lesser degree, underdiagnosis in younger individuals.
80%
predicted
FEV1/FVC
< 0.7
2
Moderate
50% ≤
Symptoms during this stage progress, with shortness of breath developing upon exertion.
FEV1 <
80%
predicted
FEV1/FVC
< 0.7
3
Severe
30% ≤
Shortness of breath becomes worse at this stage, and COPD exacerbations are common.
FEV1 <
50%
predicted
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FEV1/FVC
< 0.7
4
Very
Severe
Quality of life at this stage is gravely impaired. COPD exacerbations can be life-threatening.
FEV1 <
30%
predicted
Therapy for Mild Symptomatic COPD
Prescribe an albuterol metered-dose inhaler on an as needed basis.
Albuterol is a member of a class of medications called short-acting beta agonist (SABA) bronchodilators that improve lung function by altering airway
smooth muscle tone and reducing dynamic hyperinflation. Bronchodilators include:
Inhaled short-acting beta-2-agonists (SABA) such as albuterol; and inhaled long-acting beta-2-agonists (LABA) such as salmeterol.
Inhaled short-acting anticholinergics (SAMA) such as ipratropium; and inhaled long-acting anticholinergics (LAMA) such as tiotropium. [Note:
the MA stands for muscarinic antagonists].
Oral methylxanthines such as theophylline. These agents would be a good option if patients are unable to use or afford inhalation
medications.
Inhaled bronchodilators are essential for symptom management in COPD. According to the Global Initiative for Chronic Obstructive Lung Disease:
All patients who have intermittent symptoms should be prescribed a short-acting bronchodilator (e.g., albuterol or ipratropium) on an asneeded basis.
If symptoms are inadequately controlled, a daily dose of long-acting bronchodilator, such as salmeterol or tiotropium, should be added.
The choice between beta-2-agonist or anticholinergic therapy depends on the availability, cost, and individual response in terms of symptom
relief and side effects. Long-acting anticholinergics may be better at preventing exacerbations. Short-acting bronchodilators can be used with
long-acting bronchodilators as needed for symptom control.
Risks and side effects of inhaled or oral beta-agonists include:
Tachycardia
Long-acting beta-agonists may increase asthma exacerbations in patients with co-morbid asthma and COPD
Exaggerated somatic tremor
Hypokalemia (especially with concurrent use of thiazide diuretics)
Oral beta agonists are often more affordable than inhalers but are more likely to cause side effects.
Risks of inhaled anticholinergics include:
Dry mouth
Tooth loss from dental caries (secondary to dry mouth)
Angle closure glaucoma
Smoking cessation is the single most important treatment strategy for COPD. Assess your patient's readiness to quit smoking, recommend smoking
cessation, and provide information on available smoking cessation programs.
Other considerations:
Although COPD is usually caused by damage inflicted by long-term cigarette smoke, it is occasionally caused by alpha-1 antitrypsin deficiency, an
inherited disorder that can cause lung and liver disease. A clue that this may be present is when a patient younger than 45 years old is diagnosed
with COPD since they are not old enough to have developed the long-term effects from smoking. In such a case, especially if the patient has a
family history of the disease or evidence of liver damage, you may want to check alpha-1 antitrypsin levels—but you do not have to check this level
in all adults who have COPD.
Systemic glucocorticoids, such as prednisone, may be useful during an acute COPD exacerbation. Systemic glucocorticoids also may improve lung
function for about 20 percent of patients with stable COPD. However, the risks of chronic systemic steroid use often outweigh the benefits—
prednisone, even at a low dose, can cause serious side effects such as osteoporosis, suppression of the hypothalamus-pituitary-adrenal axis,
diabetes, cataracts, and necrosis of the femoral head. Another important side effect is steroid myopathy, which can contribute to muscle weakness,
decreased functionality, and respiratory failure in advanced COPD.
Hospitalization is indicated only for patients who need close observation and intensive treatment, like supplemental oxygen and/or continuous
nebulizer therapy. In addition, patients can be monitored closely for respiratory failure and the need for intubation and artificial ventilation.
Recommended Immunizations for Patients with COPD
Influenza, pneumococcal, pertussis, and COVID vaccines are specifically recommended for adults with COPD (see table below for more details
regarding influenza and pneumococcal vaccines).
Zoster is recommended for all adults aged 50 years and older.
For all patients who are due for a tetanus booster (needed every 10 years), either TdaP (Tetanus, Diphtheria, & acellular Pertussis) or Td (Tetanus &
Diphtheria) is needed Patients who have not received at least one dose of Tdap as a booster should receive it rather than Td to include protection
against Pertussis (whooping cough).
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Influenza vaccines
Pneumococcal vaccines
For adults aged 19 through 64 years with chronic
medical conditions (this includes those with lung
disease such as COPD). PCV15 or PCV20 should
Annually for all persons > 6 months (influenza strains are adjusted each year for be given first; if PCV15 is used, PPSV23 should
Recommended appropriate effectiveness). Vaccination is especially important for those who are be given at least one year later.
schedule
at high risk of developing flu-related complications (this includes people with lung
All adults 65 years of age and older should also
disease).
receive one dose of PCV15 or PCV20; if PCV15 is
used, PPSV23 should be given at least one year
later.
Effectiveness Reduces serious illness and death in patients with COPD by about 50%.
Side effects
Reduces the incidence of community-acquired
pneumonia in patients < 65 years old with COPD
and an FEV1 < 40% predicted.
Previous concerns administering in patients with a history of allergy to
eggs; evidence shows, however, that reactions are rare and the vaccine
can be administered under the supervision of a health care provider who
is competent in managing an allergic reaction. One new flu vaccine
preparation is made without any egg protein and is another option, if
available.
Fewer than 5 percent of patients experience side effects, which include
low-grade fever and mild systemic symptoms for 8-24 hours postimmunization.
Approximately one-third of patients
demonstrate mild side effects (e.g., pain,
erythema, and swelling at injection site)
Fever, myalgias, and more severe local
reactions are rare.
COPD Exacerbation: Definition, Etiology, Treatment, Hospitalization & Followup
Definition:
An exacerbation of COPD is defined as an event in the natural course of the disease characterized by a change in the patient's baseline dyspnea,
cough, and/or sputum that is beyond normal day-to-day variations and is acute in onset. Symptoms of an exacerbation include: Difficulty catching the
breath, chest tightness, fever, and an increase or change in cough that is more productive.
An exacerbation may warrant a change in regular COPD medications.
Patients should seek emergency medical care if their usual medications are not working and:
It is unusually hard to walk or talk (such as difficulty completing a sentence)
The heart is beating very fast or irregularly
Lips or fingernails are gray or blue
Breathing is fast and difficult, even when medication is being used
Etiology:
The most common causes of an exacerbation are infection of the tracheobronchial tree and air pollution, but the cause of about a third of severe
exacerbations cannot be identified.
Treatment:
After other diagnoses (e.g., pneumonia, pulmonary edema due to cardiac conditions, pulmonary embolism, arrhythmias) have been considered,
COPD exacerbation can be treated in the following fashion:
Inhaled bronchodilators (particularly inhaled beta 2-agonists with or without anticholinergics) and oral glucocorticosteroids are effective treatments for
exacerbations of COPD. Steroids should not be given for more than 5-7 days.
Antibiotics (also not for more than 5-7 days) should be given to:
Patients with the following three cardinal symptoms: increased dyspnea, increased sputum volume, and increased sputum purulence.
Patients with two of the cardinal symptoms, if increased purulence of sputum is one of the two symptoms.
Patients with a severe exacerbation of COPD that requires mechanical ventilation (invasive or noninvasive).
Hospitalization:
Hospitalization should be considered for patients with severe symptoms, acute respiratory failure, new physical signs (e.g., cyanosis), non-response
to initial management, serious comorbidities (e.g., heart failure), and patients without sufficient support at home. For patients needing respiratory
support, noninvasive mechanical ventilation should be used first because it improves gas exchange; reduces the work of breathing and decreases
the need for endotracheal intubation; and also decreases the length of hospital stay, and improves survival.
Follow-up:
Medications and education to help prevent future exacerbations should be considered as part of follow-up, because exacerbations affect the quality of
life and prognosis of patients with COPD.
COPD and Heart Failure
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The proposed mechanism for COPD leading to heart failure is that chronic hypoxia causes pulmonary vasoconstriction, which increases blood
pressure in the pulmonary vessels. This elevation in blood pressure causes permanent damage to the vessel walls and leads to irreversible
hypertension. The right heart eventually fails because the pump cannot sustain flow effectively against this pressure. Right heart failure leads to an
increase in preload, with peripheral edema and increased jugular venous distention.
Studies
Pulmonary Function Testing to Diagnose COPD
Pulmonary function testing (PFT) is the gold standard for diagnosing COPD. In pulmonary function testing, an FEV1/FVC ratio less than the 5th
percentile, or less than 0.7, confirms a diagnosis of COPD.
Of note: we are talking here about diagnosing COPD in a symptomatic patient. The USPSTF recommends against screening for COPD in
asymptomatic adults.
When Chest X-ray is Appropriate in Setting of Dyspnea
The current literature doesn't support the use of chest x-ray to rule in or out COPD, but some studies suggest that a chest x-ray might be helpful for
finding other causes of dyspnea.
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) Report states that a chest x-ray can be valuable in excluding alternative
diagnoses and establishing the presence of comorbidities (e.g., cardiomegaly, indicating cardiac disease).
One study evaluated the results of chest x-rays ordered in patients being evaluated for COPD and found that 14% detected potentially treatable
causes of dyspnea other than lung cancer and COPD, including:
Pneumonia
Bronchiectasis
Pulmonary fibrosis
Pleural effusion
Left ventricular failure
Possible active tuberculosis
Kyphoscoliosis (causes loss of lung volume & often caused by neuromuscular disease)
In addition, the chest radiograph found lung cancer in 2 percent of patients.
In summary, it makes sense to get a chest x-ray when a patient presents with shortness of breath, not to rule in or out COPD, but to evaluate for
other diagnoses.
Example of lung cancer seen on chest radiograph (seen in upper left lung field).
Spirometry for Diagnosis/Monitoring COPD
Spirometry is the most commonly used office-based device for lung function testing. A spirometer is a hand-held device that can easily be used in
the clinician's office by a patient with the assistance of a technician.
How it works:
1. The patient is asked first to exhale completely, then to inhale deeply.
2. Next, the patient is told to exhale rapidly into the device until all the air is exhausted from the lungs.
These two steps measure the inspiratory and expiratory flow of air, and a number of calculations can then be derived from these measurements. An
individual's spirometry results are based on comparison to predicted values of a representative healthy population (inputs to determine the
representative population include age, sex, height, and race/ethnicity). In the United States, spirometers use correction factors for individuals
identified as Black or Asian: they do not account for individuals of multicultural backgrounds, or for those whose backgrounds do not appear in
reference equations; additionally, it rests upon the premise that lung function must differ by race when we know that the variability of individuals and
genes within the broad, socially constructed categories of race, is tremendous. Further research into determining the most relevant factors that do
affect lung function, and whether to include race/ethnicity at all, is ongoing and is important to keep in mind when interpreting the results of
pulmonary function tests.
Definitions:
Forced Vital Capacity (FVC) = total amount of air the patient can expel from the lungs after a full inspiration
Forced Expiratory Volume -1 second (FEV1) = amount of air the patient can expel after a full inspiration in one second
Diagnosing COPD:
COPD causes the air in the lungs to be exhaled at a slower rate and in a smaller amount compared to a healthy person (obstructive defect). The
amount of air in the lungs will not be readily exhaled due to either a physical obstruction (such as with mucus production) or airway narrowing caused
by chronic inflammation.
Post-bronchodilator FEV1-to-FVC ratio (FEV1/FVC) less than 70% (or less than the fifth percentile) with compatible symptoms and history,
is diagnostic of COPD according to GOLD 2022 guidelines. There is evidence that this cut-off may over-and-under diagnose older and younger
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patients respectively, with uncertain clinical significance.
Further, the FEV1 impairment defines the level of COPD severity:
Post-bronchodilator FEV1 Impairment (Compared to Predicted) Severity
> 80%
Mild – GOLD 1
50-79%
Moderate – GOLD 2
30-49%
Severe – GOLD 3
< 30%
Very severe - GOLD 4
Clinical Reasoning
Differential of Shortness of Breath in Middle-Aged Patient Who Smokes
Most Likely Diagnoses
Acute
Acute bronchitis can cause cough in the absence of fever. By definition, it is of short duration, and it resolves with or without treatment.
bronchitis
Asthma
The onset of asthma is typically earlier in life, most commonly in childhood, so it is less likely here. Asthma occurs more frequently in
smokers, but the association is not as strong as it is with COPD.
COPD
A worsening winter cough could indicate COPD because breathing cold dry air causes constriction of the airways and obstructs airflow.
Shortness of breath mostly with activity in a patient with a history of smoking can often indicate COPD (the risk with smoking is dosedependent). COPD develops slowly over years, so most people are at least 40 years old when symptoms begin.
Lung
cancer
Lung cancer can cause cough. Cigarette
